Woundcare 2b/c Flashcards
Critical colonization
Point at which the host immune response is no longer able to control microorganisms in wound bed
Bacteria not yet invaded soft tissue
Arrested wound healing and unhealthy appearance of granulation tissue
Topical treatments
Cadexomer iodine
Silver
Xeroform
Hypchlorous acid soak
Infection
Invasion and multiplication of microorganisms in body tissue
Results in local cellular injury
Host defenses are overwhelmed
Infection equation
(# organisms x virulence)/host resistance
Host resistance
Immune repsonse
Blood supply
General health status
Local factors
S/s of infection local
Erythema Edema Warmth Increase pain Purulent Induration
S/s infection systemic
Fever
Elevated WBC
Red streaks from wound
Confusion or agitation
S/s infection chronic
New/increased slough Friable granulation tissue Foul odor Increased wound breakdown Sudden high glucose in diabetics Increase/changes in exudate
Clinical diagnosis of infection
Bacterial load 10^5-10^6 (will not heal)
NERD and STONEES
Sibbalds cute for superficial and deep compartment infection/inflammation
Symptoms and theranostic test
NERDS
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STONEES
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Gold standard for indicated dx
Tissue biopsy
Not w/in PT scope
Tx infection
Cleansing/ irrigation Debridement Topical anti microbial Topical antiseptics Abx
Topical antiseptics
Acetic acid Alcohol Chlorhexidine gluconate Dakins solution Gentian violet Hydrogen peroxide Povidone iodine **Hypochlorite acid - safe
Microorganism defenses
Toxins
Anderence of organism
Biofilms
Invasive factors (protease)
Endotoxins
Lipids and polysaccharides related by lysis of gram negative bacteria
Causes destruction of growth factors, receptors, tissue components
Decrease collagen deposition and cross linking, affecting tensile strength
Associated w/ surgical wound dehiscence
Extotoxins
Proteins related by both gram positive and negative bacteria during proliferation —> generalized tissue necrosis at wound surface
Biofilms
Structured community of bacteria cells enclosed in self produced polysacchardie matrix
Quorum sensing
Comm processes among cells in biofilm —> perceive how many other bacteria are in close proximity, regulation of many different processes
Disadvantage of biofilm
Resistance to anti microbial, abx, phagocytes Ability to enter into latent states Increasing species diversity Persister cells Altered gene expression
Biofilm tax
Wound cleansing/irritation Serial debridement Cadexomer iodine Flouroquinolone abx Pulsed, low dose abx Xylitol Lactoferrin
Biofilm irrigation
35 ml syringe w/ 18 gauge angiocatheter 8-12 psi
Water as effective as normal saline except immunocompormised or poor water quality
Hydrotherapy
Pulsed lovage w/ or w/out suction
Whirlpool
Softening necrotic tissue, reduce bioburden, remove debris, promot granulation, treatments of tunnels and undermining
Pulsed lavage setup
8-12 psi
2-6 at tunnels
60-200 mm hg suction
1 bag of irritant
Pulsed lavage precautions
Insensate pts Anticoagulant meds Wound near major vessels Wounds near a cavity lining Bypass graft sites Exposed structures Grafts Flaps Facial
Whirlpool
Necrotic tissue - softens, reduce bioburnder, remove debris
92-96 deg, 5-20 mins, monitor
Precautions: edema, CHF, heart conditions
Contras: new skin graft/flap, suture, IV sites
Wound bed moisture balance
Too much exudate: maceration, pooling
Too little: desiccation
Too wet, absorb
Too dry, moisten
Benefits of moist wound healing
- Optimal enviro
- Reduces number of dressing changes (time and cost)
- reduces potential for infection
- less painful
- decrease healing time
- stronger scar formation
Ideal dressing characteristics
- barrier to bacteria
- adequate gaseous exchange
- thermal insulation
- free from contaminants
- manages excess exudate
- facilitates nontraumatic removal
Dressings - absorption
Alginate
Foam
Hydrocolloid
Hydrofiber
Dressing - hydration/moisture maintenance
- hydrogel
- impregnated gauze
- hydrocolloid
- transparent film
Dressings - antimicrobial
- cadexomer iodine
- silver
- honey
Enzymatic debridement
Collagenase santyle
Protection of periwound
Ointments
Creams
Films
Hydrocolloid
Alginate
Non - woven pad of seaweed fibers, non occlusive, conformable, slow bleeding, forms gel when filled w/ fluid
Ad:highly absorbent;packing;easy to use; hemostasis properties
Ind: mod to heavy exudate, contaminated or infected, slough or granulation
Foam
Absorption
High density polyurethane
Ad: nonadhesive, friable periwound, large variety
Indication: minimal to heavy exudate, not recommended for infected wounds
Hydrocolloid
Absorption, hydration/moisture
Ad: adhesive, absorptive, conformable, promotes autolysis, also able to maintain most wound bed
Indications: dry to minimal exudate, aloud or granulation
Hydrofiber
Absorption
Packing agen, easy, 33% more absorbent than alginate
Moderate to heavy exudate, contaminated or infected, slough or granulation
Hydrogel
Hydration, moisture maintain
Cooling effect,amorphous, promotes autolysis, keeps structures moist
Dry to minimal exudate, eschar, slough, granulation; deep structures exposed
Impregnated gauze
Hydration, moisture
Highly confomrative, maintains moisture, nonadherent, promotes autolysis
Keeps structures moist
Dry to minimal exudate, eschar, slough, granulation, deep structures exposed
Transparent film
Mosture
Promotes autopsies, reduces surface tension *may hold in too much moisture
Dry to minimal exudate, partial thickness wounds or as secondary dressing
Cadexomer iodine
Iodine Released over 72 hours, starch beads absorb exudate
Absorptive and odor reducing
Moderation to easy exudate, infected, malodorous wounds
Contras: hyperthyroid, iodine sensitivity
Silver
Antimicrobial, reduces inflammation
Critically colonized/infected wounds or those at risk of becoming infected
Contra: use w/ enzymatic debridement, some not compatible w/ saline
Honey
Antimicrobial, draws fluid from wound by osmotic pressure, reduces odor, aids in debridement
For critically conolized/infected wounds, those at risk for infection, necrotic
Not for use w/ enzymatic debridement
Collagenase santyl
Debriding ointment w/ enzymes derived from bacteria
Desires collagen anchors to wound bed
For wound w/ necrotic tissue
Contra: use w/ silver dressings, pt hypersensitivity to substance
Ointments, creams, liquid films
Protect periwound, provides a barrier, smooth irritated skin
Physical agents for epithelial advancement
Electrical stim Non contract US UVC light Negative pressure Hyperbaric oxygen Compression
E-stim
Most nonhealing wounds
Reimbursement: must have received evidence based wound care for at least 4 weeks w/ little to no progress
Estimate - high volt pulsed current
3-5x/week
Active electrode to wound, dispersal pad to intact skin w/ list cause or washcloth
Non contact US
Most nonhealing wounds, all healing phases, not generally reimbursed
Saline as conduit
Contras: eclectic implants, low back/abs during pregnancy, over malignancy
Increased healing rate in non diabetic foot ulcer, ischemic wounds
UVC
Infection, impaired wound healing
Benefit: increased epithelial migration, local cutaneous blood flow, bactericides effects, inhibit growth of MRSA and VRE
Perpendicular to wound surface, 2.5cm away, 90 seconds daily
UCV contras
Skin CA Graft photosensitivity Skin conditions Keep X-ray therapy Local erythema AIDS/HIV Eye No CHF, TB, DM, hyperthyroid, fever
Hyperbaric oxygen wound indications
osteomyelitis, diabetic
wounds, necrotizing soft tissue infections,
osteoradionecrosis, soft tissue radionecrosis,
compromised grafts and flaps, acute thermal
burns, crush injury, compartment syndrome and
other acute traumatic ischemias
Hyperbaric oxygen benefits
Increase oxygen concentration in tissue
Stimulates new blood vessel growth
Negative pressure indications
Nonhealing/chronic wounds Post sx/ traumatic wounds As a bridge to tertiary closure Skin grafts and flaps Enterocutaneous fistula
Negative pressure precuations
Anticoagulants Elevated IRN Low platelets Active bleeding Poor tolerance of VAC therapy
Negative pressure contras
Malignancy
Untreated osteomyelitis
Nonenteric and unexplored fistulas
Majority of wound necrotic
Negative pressure challenges
Wounds w/ enterocutaneous fistulas
In proximity to external fixations, moist areas, sacrum/coccyx/perineum
Tubing
Exposed structures
Negative pressure solutions
Bridging Ostomy pouches in conjunction w/ NPWT Ostomy paste strips Benzoin tincture Adaptic/merited/white foam
7 types of edema in legs
Venous Cardiac Lymphedema Inflammatory Idiopathic Hypoproteinaemic renal
Edema tax
Meds Treatment of medical cause Manual lymph drainage ELEVATION COMPRESSION
Compression physio
Reduce diameter of veins -> endothelial cells to become tighter-> reduce fluid leakage from veins
Increase in BF toward heart and reduces venous reflux
Degree of compression determined by
Elasticity of bandage Number of bandage layers Shape and size of limb Skill and technique of bandage Nature of physical activity by pt
Laplace law
For bandage pressure
Pa-Pb= (2y/r)
Pa = internal Pb = external Y = tension r = radius
Increased bandage tension
Increased sub bandage pressure
Increased # bandage layers
Increased sub bandage pressure
Increased leg circumference
Decreased sub bandage pressure
Increased bandage width
Decreased sub bandage pressure
2 pain bandage types
Long stretch (more aggressive compression)
Short stretch (safer due to less extensibility -> less tension to limb)
Long stretch bandage
High resting pressure Low working pressure Higher risk of damage >140% ext Polyurethane
Short stretch bandage
Low resting pressure High working pressure Lower risk of damage ~60% ext Made from cotton fibers
Resting pressure
Pressure bandage exerts on tissue at rest
Working pressure
Pressure bandage exerts against working musculature
Compression precautions
DM PVD/arterial insufficiency Acute cellulitis/infection Neuropathy Lymphedema Acute CHF Low ejection fraction Fragile skin
Compression contras
ABI <0.6
High compression (30-40 mmHG) W/ ABO <0.8
Compression progression - wounds
Open: wraps, maybe Velcro compression garment
Closed: stockings or compression garments
Pt instructions for compression stockings
Wear during waking hours when OOB
Do not moisturize prior to applying
Wound recalcitrance
Elevation of LE above heart when sitting
Importance and purpose of wraps/stockings
Monitoring for changes such as CHF, cellulitis, vascular status
Red flags - refer to MD
Worsening cellulitis Cellulitis in diabetic or elderly population Unusual exudate from any wound Increase in depth, bone/tendon exposure Deep compartment infection Purple coloration Digits eschar Sig area of eschar of foot/hand Nonhealing wound after 2-3 mo
